HomeMy WebLinkAboutPR 22529: CONTRACT WITH THE DEPARTMENT OF STATE HEALTH SERVICES IMMUNIZATION BRANCH. NO MATCH REQUIRED E.A
City of
NMI
o rt rth u ��
Date: April 25, 2022
To: Ron Burton, City Manager
From: Judith A. Smith, RN, BSN, Director of Health Services
RE: Contract Amendment between the City of Port Arthur and the Department of
State Health Services Immunization Branch. No match required
Nature of the Request: This contract amendment will allow the Health Department to continue
its immunization program for children, adolescents and adults to eliminate barriers, expand
immunization delivery, and establish uniform policies. The contract period is from September 1,
2022 to August 31, 2023. The contract budget is amended to add funding for state fiscal year
2023 in the amount of $162,630.00. The total amount of the grant award will not exceed
$875,366.00. There is no cash match for this grant.
Staff Analysis, Considerations: These grant funds cover salaries and fringe for 3 full-time
employees, one licensed nurse, one Administrative staff and one Community Outreach staff.
Recommendations: It is recommended that the City Council approve P.R. No. 22529, amending
the contract between the City of Port Arthur and the Department of State Health
Services/Immunization Division. This grant will allow the Health Department to continue the
immunization program for children, adolescents, and adults.
Budget Considerations: This grant will cover personnel salaries and fringe benefits. The
additional funds will help fund staff for the COVID vaccination Hub.
"REMEMBER WE ARE HERE TO SERVE THE CITIZENS OF PORT ARTHUR"
P.O.BOX 1089•PORT ARTHUR,TX 77641-1089.409/983-8101•FAX 409/982-6743
P. R. No. 22529
04/25/2022-js
RESOLUTION NO.
A RESOLUTION APPROVING THE FY 2022-2023 CONTRACT
AMENDMENT BETWEEN THE CITY OF PORT ARTHUR AND THE
DEPARTMENT OF STATE HEALTH SERVICES, IMMUNIZATION
BRANCH-LOCAL TO EXTEND THE CONTRACT PERIOD THROUGH
AUGUST 31, 2023 AND ADD FUNDING IN THE AMOUNT OF
$162,300.00. THE TOTAL AMOUNT OF THIS CONTRACT WILL NOT
EXCEED $875,366.00. NO CASH MATCH IS REQUIRED.
WHEREAS, the contract between the City of Port Arthur and the Department of State
Health Services provides financial assistance to the Port Arthur City Health Department to
supplement the delivery of public health services. This contract amendment will allow the City's
Health Department to continue the immunization program for children, adolescents, and adults
and will help to eliminate barriers, expand immunization delivery, and establish uniform
policies; and,
WHEREAS, pursuant to Resolution No.21-123, council approved the FY 2021-2022
contract on March 30, 2022, and now The Department of State Health Services desires to amend
the contract to add $162,630.00 to cover the contract period September 1, 2022 through August
31, 2023. The total grant award will not exceed $875,366.00.
NOW THEREFORE BE IT RESOLVED BY THE CITY COUNCIL OF THE
CITY OF PORT ARTHUR:
Section 1. That, the facts and opinions in the preamble are true and correct.
Section 2. That, the City Council of the City of Port Arthur hereby approves the
contract amendment between the City of Port Arthur and the Department of State Health
Services.
P. R. No. 22529
04/25/2022-js
Section 3. That, the City Council deems it is in the best interest of the City to
approve and authorize the City Manager and the Director of the City's Health Department to
execute the contract amendment between the Department of State Health Services and the City
of Port Arthur, Texas, to continue the immunization program as delineated in Exhibit"A".
Section 4. That, a copy of the caption of this Resolution be spread upon the Minutes
of the City Council.
READ, ADOPTED, AND APPROVED, this day of May, 2022 A.D., at a
Regular Meeting of the City Council of the City of Port Arthur, Texas by the following Vote:
AYES: Mayor: ,
Councilmembers:
NOES:
Mayor
ATTEST:
Sherri Bellard, City Secretary 1AP OVED AS TO FORM:
(iiit-e (tom f�7
Val Tizeno, ity Attorney t�
P. R. No. 22529
04/25/2022-js
APPROVED FOR ADMINISTRATION:
9.Ud v /in lib
Ron Burton, City Manager Judith Smith, RN, BSN, Director of Health
EXHIBIT "A"
DocuSign Envelope ID:B2CCD95C-F3AB-4BF8-9618-4AC2AA9A5FD1
DEPARTMENT OF STATE HEALTH SERVICES
CONTRACT No.HHS000109900001
AMENDMENT No. 4
The DEPARTMENT OF STATE HEALTH SERVICES (DSHS or System Agency) and CITY OF PORT
ARTHUR (Grantee), Parties to that certain Immunization/Locals Grant Program Contract, effective
September 1, 2018, and denominated DSHS Contract No. HHS000109900001 (the Contract), as
amended, now want to further amend the Contract.
WHEREAS, DSHS wants to exercise its option to extend the Contract term for an additional
year, representing the fourth and final extension option("Fourth and Final Extension Option");
WHEREAS, DSHS wants to add funds to the Contract to pay for services provided during the
extended term;
WHEREAS, DSHS wants to revise ATTACHMENT A, STATEMENT OF WORK and
ATTACHMENT H-2,IMMUNIZATION/LOCALS PROGRAM GUIDANCE DOCUMENT.
Now,THEREFORE, the Parties agree as follows:
1. The Contract is extended in accordance with SECTION III,DURATION, for an additional
year. The Fourth and Final Extension Option shall begin September 1, 2022 and end
August 31, 2023, unless terminated sooner.
2. SECTION IV, BUDGET, of the Contract, is amended to increase funding in the amount of
$162,630.00 for State Fiscal Year 2023 ("FY 2023"). The total not-to-exceed amount of
this Contract is increased to $875,366.00. All expenditures of the additional funds must
conform with ATTACHMENT B-4,FY 2023 BUDGET.
3. ATTACHMENT A-1, REVISED STATEMENT OF WORK, of the Contract, is deleted and
replaced in its entirety with ATTACHMENT A-2,FY 2023 STATEMENT OF WORK.
4. ATTACHMENT B-3, REVISED BUDGET, of the Contract, is supplemented with the
addition of ATTACHMENT B-4,FY 2023 BUDGET.
5. ATTACHMENT H-2, IMMUNIZATION/LOCALS PROGRAM GUIDANCE DOCUMENT is
deleted and replaced in its entirety with ATTACHMENT H-3, IMMUNIZATION/LOCALS
PROGRAM GUIDANCE DOCUMENT.
6. This Amendment shall be effective September 1, 2022.
7. Except as modified by this Amendment, all terms and conditions of the Contract, as
amended, shall remain in full force and effect.
DSHS Contract No.HHS000109900001 Page 1 of 33
Amendment 4
DocuSign Envelope ID:B2CCD95C-F3AB-4BF8-9618-4AC2AA9A5FD1
8. Any further revisions to the Contract shall be by written agreement of the Parties.
SIGNATURE PAGE FOLLOWS
DSHS Contract No.HHS000109900001 Page 2 of 33
Amendment 4
DocuSign Envelope ID:B2CCD95C-F3AB-4BF8-9618-4AC2AA9A5FD1
SIGNATURE PAGE FOR AMENDMENT No. 4
DSHS CONTRACT No. HHS000109900001
DEPARTMENT OF STATE HEALTH CITY OF PORT ARTHUR
SERVICES
By: By:
Date of Signature: Date of Signature
THE FOLLOWING DOCUMENTS ARE ATTACHED TO THIS AMENDMENT AND THEIR TERMS ARE
INCORPORATED INTO THE CONTRACT BY REFERENCE:
ATTACHMENT A-2—FY 2023 STATEMENT OF WORK
ATTACHMENT B-4 -FY 2023 BUDGET
ATTACHMENT F-4 -FEDERAL FUNDING ACCOUNTABILITY AND
TRANSPARENCY ACT(FFATA)
ATTACHMENT H-3- IMMUNIZATION/LOCALS PROGRAM GUIDANCE
DOCUMENT
ATTACHMENTS FOLLOW
DSHS Contract No.HHS000109900001 Page 3 of 33
Amendment 4
DocuSign Envelope ID:B2CCD95C-F3AB-4BF8-9618-4AC2AA9A5FD1
ATTACHMENT A-2
FY 2023 STATEMENT OF WORK
I.GRANTEE RESPONSIBILITIES
Grantee will:
A. Implement and operate an immunization program for children, adolescents, and adults,
with special emphasis on accelerating interventions to improve the immunization
coverage of children three (3) years of age or younger (birth to 35 months of age).
Grantee shall incorporate traditional and non-traditional systematic approaches
designed to eliminate barriers, expand immunization capacity, and establish uniform
operating policies, as described herein.
B. Be enrolled as a provider in the Texas Vaccines for Children (TVFC) and the Adult
Safety Net (ASN) Programs by the effective date of this Contract. This includes a
signed Deputization Addendum Form (EF11-13999).
C. Comply with written policies and procedures provided by DSHS in managing vaccines
supplied through the ASN and TVFC Programs, including guidelines for proper
storage, handling, and safeguarding of vaccines in the event of natural disaster.
D. Adhere to DSHS Immunization updated guidance according to Attachment H-3,
Immunization/Locals Program Guidance Document.
E. Maintain staffing levels to meet required activities of the Contract and ensure staff
funded by this Contract attend required training.
F. Report all notifiable conditions as specified in Texas Administrative Code(TAC)Title
25, Part I §§ 97.1-97.6, as amended, and as otherwise required by law.
G. Report all vaccine adverse event occurrences in accordance with the 1986 National
Childhood Vaccine Injury Act (NCVIA) 42 U.S.C. § 300aa-25 (located at
http://vaers.hhs.gov/ or 1-800-822-7967), as amended.
H. Sustain a network of TVFC/ASN providers to administer vaccines to program-eligible
populations by conducting the following activities:
1. Ensuring New Provider Checklist is completed;
2. Conducting quality assurance reviews;
3. Ensuring annual influenza pre-book survey is completed;
4. Conducting compliance site-visits;
5. Conducting unannounced storage and handling visits; and
6. Ensuring providers adhere to the vaccine borrowing procedure.
I. Participate in audits and assessments through the following activities:
DSHS Contract No.HHS000109900001 Page 4 of 33
Amendment 4
DocuSign Envelope ID:B2CCD95C-F3AB-4BF8-9618-4AC2AA9A5FD1
1. Completing and submitting through Child Health Reporting System(CHRS)all
audits and assessments conducted on childcare facilities and Head Start
Centers;
2. Completing audits, assessments and retrospective surveys of public and private
schools;
3. Reviewing monthly reports to ensure data quality;
4. Reviewing the monthly Provider Activity Reports;
5. Reviewing the quarterly Consent Accepted Rate Evaluations; and
6. Conducting quality improvement assessments of Texas Immunization Registry
organizations.
J. Provide education and outreach activities regarding vaccines and vaccine-preventable
diseases, Texas Immunization Registry, and TVFC and ASN Programs to the
following:
1. American Indian Tribes;
2. Schools and childcare facilities;
3. Healthcare workers; and
4. Community and general public.
K. Not deny vaccinations to recipients because they do not reside within Grantee's
jurisdiction or because of an inability to pay an administration fee.
L. Be responsible for identification and case management of all hepatitis B surface antigen
(HBsAg)-positive pregnant women. Grantee shall ensure timely newborn post-
exposure prophylaxis (PEP) with hepatitis B vaccine and hepatitis B immune globulin
(HBIG), timely completion of doses two and three of hepatitis B vaccine, and timely
completion of post-vaccination serologic testing(PVST).
M. Be responsible for assessing and/or auditing coverage rates and/or compliance with
vaccine requirements at assigned schools and childcare facilities in accordance with the
Population Assessment Manual, which is distributed annually from DSHS.
N. Transfer(which may include shipping)overstocked vaccines and vaccines approaching
expiration to alternate providers for immediate use when instructed to do so by the
DSHS Public Health Region(PHR) Immunization Program Manager to avoid vaccine
waste. Grantee is responsible for covering the cost to ship overstocked vaccines and
vaccines approaching expiration.
O. Receive written approval from DSHS before varying from applicable policies,
procedures, protocols, and/or work plans, and must update and disseminate its
implementation documentation to its staff involved in activities under this Contract
within forty-eight (48)hours of making approved changes.
P. Review monthly Contract funding expenditures and salary savings from any Contract-
paid staff vacancies and revise spending plan to ensure that all funds will be properly
expended under this Contract before the end of the Contract term.
DSHS Contract No.HHS000109900001 Page 5 of 33
Amendment 4
DocuSign Envelope ID:B2CCD95C-F3AB-4BF8-9618-4AC2AA9A5FD1
Q. Submit out-of-state travel requests to the Immunization Section for approval when
utilizing Contract funds or program income.
R. Report the number of doses administered to underinsured children monthly,as directed
by DSHS.
S. Report the number of unduplicated underinsured clients served, as directed by DSHS.
T. Complete and submit Immunization Inter-Local Agreement (ILA) Quarterly Report
form, utilizing the format provided by the DSHS Immunization Section and available
at https://dshs.texas.gov/immunize/lhd.shtm,by the report due date. If the due date falls
on a weekend or state approved holiday, the report is due the next business day.
Report Type Reporting Period Report Due Date
Programmatic 09/1/2022 to 11/30/2022 12/31/2022
Programmatic 12/1/2022 to 02/28/2023 03/3 1/2023
Programmatic 03/1/2023 to 05/30/2023 06/30/2023
Programmatic 06/1/2023 to 08/31/2023 09/30/2023
Submit quarterly reports electronically through an online tool according to the
timeframes stated above. DSHS Immunization Section will provide instructions at the
beginning of each state fiscal year through CMS. Supplemental report documents
(PEAR and AFIX reports, vacancy letters, etc.) should be sent to
dshsimmunizationcontracts(c,dshs.texas.gov.
II. PERFORMANCE MEASURES
A. The System Agency will monitor the Grantee's performance of the requirements in this
Attachment A-2 and compliance with the Contract's terms and conditions.
III. INVOICE AND PAYMENT
A. Grantee shall request monthly payments using the State of Texas Purchase Voucher
(Form B-13) at http://www.dshs.texas.gov/grants/forms.shtm and submitting
acceptable supporting documentation for reimbursement of the required
services/deliverables. Vouchers and supporting documentation shall be submitted to
System Agency no later than thirty (30) days after the last day of each month.
Documentation shall be submitted in a format approved by DSHS Immunization
Section.
At a minimum vouchers should include:
1. Grantee name, address, email address,vendor identification number,and telephone
number;
DSHS Contract No.HHS000109900001 Page 6 of 33
Amendment 4
DocuSign Envelope ID:B2CCD95C-F3AB-4BF8-9618-4AC2AA9A5FD1
2. DSHS Contract or Purchase Order number;
3. Dates services were completed and/or products were delivered;
4. The total invoice amount; and
5. DSHS Supporting documentation.
B. Voucher and supporting documentation shall be mailed or submitted by fax or
electronic mail to DSHS Claims Processing Unit at the address/number below, and to
the Immunization Section at DSHSImmunizationContracts@dshs.texas.gov.
Department of State Health Services
Claims Processing Unit, MC 1940
1100 West 49th Street
P.O. Box 149347
Austin, TX 78714-9347
FAX: (512)458-7442
EMAIL: invoices a,dshs.texas.gov and to CMSinvoices@dshs.texas.gov
Grantee will be paid on a cost reimbursement basis and in accordance with the Budget in
Attachment B-4, FY 2023 Budget of this Contract.
DSHS Contract No.HHS000109900001 Page 7 of 33
Amendment 4
DocuSign Envelope ID:B2CCD95C-F3AB-4BF8-9618-4AC2AA9A5FD1
ATTACHMENT B-4
FY 2023 BUDGET
Organization Name: City of Port Arthur
Program ID: IMM/LOCALS
Contract Number: HHS000109900001
Budget for FY 2023
Budget Categories September 1, 2022 -
August 31, 2023
Personnel $127,763.00
Fringe $34,867.00
Travel $0.00
Equipment $0.00
Supplies $0.00
Contractual $0.00
Other $0.00
Total Direct $162,630.00
Indirect $0.00
Total $162,630.00
Remainder of page intentionally left blank
DSHS Contract No.HHS000109900001 Page 8 of 33
Amendment 4
DocuSign Envelope ID:B2CCD95C-F3AB-46F8-9618-4AC2AA9A5FD1
ATTACHMENT F-4
Fiscal Federal Funding Accountability and Transparency Act
(FFATA)CERTIFICATION
The certifications enumerated below represent material facts upon which DSHS relies when reporting
information to the federal government required under federal law. If the Department later determines
that the Contractor knowingly rendered an erroneous certification, DSHS may pursue all available
remedies in accordance with Texas and U.S. law. Signor further agrees that it will provide immediate
written notice to DSHS if at any time Signor learns that any of the certifications provided for below were
erroneous when submitted or have since become erroneous by reason of changed circumstances. If the
Signor cannot certify all of the statements contained in this section, Signor must provide written
notice to DSHS detailing which of the below statements it cannot certify and why.
Legal Name of Contractor: FFATA Contact#1 Name,Email and Phone Number:
City of Port Arthur Judith A.Smith,RN BSN
judith.smith@portarthurtx.gov
(409)983-8832
Primary Address of Contractor: FFATA Contact#2 Name,Email and Phone Number:
449 Austin Avenue Kandy Daniel
Port Arthur,TX,77640 kandy.daniel@portarthurtx.gov
(409)983-8174
ZIP Code:9-digits Required www.usps.com DUNS Number:9-digits Required www.sam.gov
776110 5,802 13713109
State of Texas Comptroller Vendor Identification Number(VIN)14 Digits
174,001885p011
Printed Name of Authorized Representative Signature of Authorized Representative
Judith A. Smith p—Docusigned by:
itAli w StMI
Title of Authorized Representative be{€B48504AED30471...
Director of Health
April 22,2022
-1-
Department of State Health Services Form 4734—June 2013
DSHS Contract No.HHS000109900001 Page 9 of 33
Amendment 4
DocuSign Envelope ID:B2CCD95C-F3AB-4BF8-9618-4AC2AA9A5FD1
Fiscal Federal Funding Accountability and Transparency Act
(FFATA)CERTIFICATION
As the duly authorized representative(Signor)of the Contractor,I hereby certify that
the statements made by me in this certification form are true,complete and correct to
the best of my knowledge.
Did your organization have a gross income, from all sources, of less than $300,000 in
your previous tax year?❑Yes b7 No
If your answer is"Yes",skip questions"A","B",and"C"and finish the certification.
If your answer is"No",answer questions"A"and"B".
A.Certification Regarding%of Annual Gross from Federal Awards.
Did your organization receive 80% or more of its annual gross revenue from federal
awards during the preceding fiscal year?❑Yes No
B.Certification Regarding Amount of Annual Gross from Federal Awards.
Did your organization receive$25 million or more in annual gross revenues from federal
awards in the preceding fiscal year?❑Yes ail No
If your answer is"Yes"to both question"A"and"B",you must answer question"C".
If your answer is "No" to either question "A" or "B", skip question "C" and finish the
certification.
C.Certification Regarding Public Access to Compensation Information.
Does the public have access to information about the compensation of the senior
executives in your business or organization (including parent organization, all branches,
and all affiliates worldwide)through periodic reports filed under section 13(a) or 15(d)
of the Securities Exchange Act of 1934(15 U.S.C. 78m(a), 78o(d))or section 6104 of the
Internal Revenue Code of 1986?[]Yes ❑ No
If your answer is"Yes"to this question,where can this information be accessed?
Information can be accessed through the City Secretary's office
If your answer is "No" to this question, you must provide the names and total
compensation of the top five highly compensated officers below.
Provide compensation information here:
N/A
-2-
Department of State Health Services Form 4734—June 2013
DSHS Contract No.HHS000109900001 Page 10 of 33
Amendment 4
DocuSign Envelope ID:B2CCD95C-F3AB-4BF8-9618-4AC2AA9A5FD1
ATTACHMENT H-3
IMMUNIZATION/LOCALS PROGRAM GUIDANCE DOCUMENT
GRANTEE RESPONSIBILITIES
1. PROGRAM& CONTRACT MANAGEMENT
1.1. PROGRAM MANAGEMENT
1.1.01 Implement and operate an Immunization Program as a Standard
Responsible Entity (Universal)
1.1.02 Identify at least one individual to act as the program contact in Required
the following areas: Activity
1. Immunization Program Manager;
2. RE Contract Coordinators;
3. RE School Compliance Coordinators;
4. RE Perinatal Hepatitis B Case Manager;
5. RE Disease Surveillance Coordinators;
6. RE Clinical Coordinators;
7. RE Texas Immunization Registry Coordinators;
8. RE TVFC & ASN Coordinators; and
9. RE Coalition Coordinators
1.1.03 Attend all required trainings for each Area of Work as specified Required
in the Immunization Program Contractor's Guide. Ensure that Activity
the Immunization Program Manager and TVFC and ASN
Coordinator attend the annual Immunization Unit mandatory in-
person meeting
1.1.04 Comply with the DSHS Immunization Contractor's Guide for Standard
Local Health Depat tinents which includes all immunization (Universal)
grant objectives and required activities. The Immunization
Contractor's Guide is Attachment A of the ILA and will be
attached to the executed contract
1.1.05 Annually complete one LHD Deputization Addendum Form Required
(EF11-13999) for all Provider Identification Numbers (PIN) Activity
associated with the LHD Grantee to ensure eligibility to provide
immunization services to underinsured children
1.1.06 Maintain staffing levels adequate to meet the required activities Standard
of this contract and to assure expenditure of all contract funds (Universal)
DSHS Contract No.HHS000109900001 Page 11 of 33
Amendment 4
DocuSign Envelope ID:B2CCD95C-F3AB-4BF8-9618-4AC2AA9A5FD1
1.1.07 Develop and implement an employee immunization policy for Required
Grantee's immunization program staff according to CDC Activity
recommendations
1.1.08 Maintain a record of orientation (new staff) and ongoing Required
training for existing contract-funded staff involved in the Activity
provision of immunization services
1.1.09 Inform DSHS (in writing) of any changes (both departures and Required
arrivals) in LHD Medical Director, Immunization Program Activity
Manager and all other positions listed under activity 1.1.02
within 30 days of staffing changes
1.1.10 Submit a written notification for contract-funded staff positions Required
that remain vacant more than 90 days Activity
1.1.11 Have a standard method to document all work time spent Standard
performing immunization activities for staff who are partially (Universal)
funded with immunization contract funds
1.1.12 Use the results of the community assessment conducted in Suggested
activity 4.7.01 to review and address an immunization need Activity
within the LHD jurisdiction
1.2. PROGRAM COMPLIANCE
1.2.01 Comply with all applicable federal and state regulations and Standard
statutes as amended, including, but not limited to: (Universal)
1. Texas Human Resources Code §42.043;
2. Texas Education Code §§38.001-38.002;
3. Texas Health and Safety Code §§12.032-12.033, 81.023,
and 161.001-161.009;
4. Texas Administrative Code (TAC) Title 25, Chapter 97;
5. TAC Title 25, Chapter 96;
6. TAC Title 25, Chapter 100;
7. 42 USC §§247b and 300aa-25;
8. Omnibus Budget Reconciliation Act of 1993; and
9. 26 USC §4980B
1.2.02 Ensure compliance with Health and Human Services (HHS) Standard
Deputization Guidance. Activities under this requirement (Universal)
shall be conducted in accordance with the DSHS
Immunization Contractor's Guide for Local Health
Depai tments
1.3. FINANCIAL MANAGEMENT
DSHS Contract No.HHS000109900001 Page 12 of 33
Amendment 4
DocuSign Envelope ID:B2CCD95C-F3AB-4BF8-9618-4AC2AA9A5FD1
1.3.01 Agree DSHS reserves the right, where allowed by legal Standard
authority,to redirect funds in the event of financial shortfalls (Universal)
1.3.02 Submit monthly invoices with appropriate supplemental Required
documentation and request monthly payments using the State Activity
of Texas Purchase Voucher(Form B-13) and in accordance
with the DSHS Immunization Contractor's Guide for Local
Health Departments
1.3.03 Agree DSHS will pay Grantee on a cost reimbursement basis Standard
(Universal)
1.3.04 Adhere to travel rates set by the State of Texas TexTravel Standard
unless the LHD has their own travel poli y. (Universal)
1.3.05 Review monthly contract funding expenditures to ensure that all Standard
funds will be properly expended before the end of the contract (Universal)
period
1.3.06 Lapse no more than 5 percent of total funded amount of the Required
contract Activity
1.3.07 Submit requests to move more than 25% of the total contract Standard
amount between direct budget categories in writing to the (When
DSHS Contract Management Section(CMS) in Austin and Applicable)
obtain approval before monies can be transferred
1.3.08 Expend funds consistently throughout the contract term, Suggested
approximately 25%per quarter Activity
1.4. CONTRACT MANAGEMENT
1.4.01 Initiate the purchase of approved equipment purchases in the first Standard
quarter of the Contract term. Requests to purchase previously (When
approved equipment after the first quarter must be submitted to the Applicable)
contract manager. Changes to the approved equipment budget
category must be approved by DSHS prior to the purchase of
equipment. If a Grantee would like to deviate from the approved
equipment budget, a written request to amend the budget is required
1.5. CONTRACT QUALITY ASSURANCE
1.5.01 Participate in remote and on-site technical assistance Required
Activity
1.5.02 Participate in on-site contract evaluation visits Required
Activity
DSHS Contract No.HHS000109900001 Page 13 of 33
Amendment 4
DocuSign Envelope ID:B2CCD95C-F3AB-4BF8-9618-4AC2AA9A5FD1
1.6. CONTRACT ACCOUNTABILITY
1.6.01 Submit Corrective Action Plan(CAP) letter to Public Health Region Required
Program Manager and DSHS Contract Management Section(CMS) Activity
within 30 days after the date of the written notification from DSHS
CMS of the on-site evaluation findings (if applicable)
1.6.02 Maintain property records for property and equipment funded or Standard
property provided by grant funds (Universal)
1.7. REQUIRED REPORTING
1.7.01 Complete and submit Immunization Inter-Local Agreement(ILA) Required
Quarterly Report and supplemental documents according to the Activity
formats, mechanisms, and timeframes specified in the DSHS
Immunization Contractor's Guide for Local Health Departments
1.7.02 Report program income (PI) generated as a result of the DSHS Required
immunization contract activities on the quarterly financial status Activity
report(FSR)
1.7.03 Ensure all program income (PI) generated as a result of the DSHS Standard
immunization contract activities is expended in accordance with the (Universal)
DSHS Immunization Contractor's Guide for Local Health
Departments
1.7.04 Submit quarterly FSRs to Accounts Payable by the last business Required
day of the month following the end of each quarter for review and Activity
financial assessment. Submit the final FSR no later than forty-five
(45) calendar days following the end of the applicable term
2. FACILITY IMMUNIZATION ASSESSMENTS
2.1. CHILDCARE& SCHOOL COMPLIANCE
2.1.01 Assess compliance with vaccine requirements at assigned Standard
schools and childcare facilities (Universal)
2.1.02 Complete 100%of assigned childcare facility Required
audits/assessments. By July 15 of contract year, local health Activity
department staff will complete 100%of assigned childcare
audits and submit into the Child Health Reporting System
(CHRS)
DSHS Contract No.HHS000109900001 Page 14 of 33
Amendment 4
DocuSign Envelope ID:B2CCD95C-F3AB-4BF8-9618-4AC2AA9A5FD1
2.1.03 Complete 100%of assigned public and private school audits, Required
assessments, and/or validation/retrospective surveys in Activity
accordance with the DSHS Immunization Contractor's Guide
for Local Health Departments by June 15 of contract year,
local health department staff will complete 100% of assigned
school audits and submit electronically(Alchemer,possibly
via email)
2.2. CHILDCARE& SCHOOL COMPLIANCE QA
2.2.01 Provide education to school and childcare facilities with high Required
provisional, delinquency, and/or exemption rates at time of Activity
audit or when noncompliant records are identified. Report
education provided to school or childcare staff in accordance
with the DSHS Immunization Contractor's Guide for Local
Health Departments
2.2.02 Provide feedback to DSHS ACE Group regarding Required
trends/issues for vaccine requirements in accordance with the Activity
DSHS Immunization Contractor's Guide for Local Health
Departments
2.2.03 Contact schools/districts to remind them to report during the Required
Annual School Survey reporting period in accordance with Activity
the DSHS Immunization Contractor's Guide for Local Health
Departments
2.3. FIRST RESPONDER IMMUNIZATION ASSESSMENTS
2.3.01 Educate and inform first responder facilities on the use of the Suggested
Texas Immunization Registry to assess first responder Activity
immunization records and forecast any future immunization
needs. Use the First Responder Immunization Toolkit(FRIT)
to drive these activities
3. MANAGING TVFC AND ASN PROVIDERS
3.1. PROVIDER RECRUITMENT
3.1.01 Recruit additional TVFC providers to administer vaccines to Suggested
program-eligible populations. The goal is to increase each Activity
local health department's provider enrollment by 5%
DSHS Contract No.HHS000109900001 Page 15 of 33
Amendment 4
DocuSign Envelope ID: B2CCD95C-F3AB-4BF8-9618-4AC2AA9A5FD1
3.1.02 Ensure New Enrollment Checklist(11-15016)is completed Required
for all clinics that join the TVFC/ASN Program Activity
3.1.03 Collaborate with medical societies and/or local health Suggested
provider organizations to identify providers to recruit and Activity
enroll
3.2. PROVIDER RETENTION
3.2.01 Sustain a network(through re-enrollment)of TVFC providers Required Activity
to administer vaccines to program-eligible populations
3.2.02 Promote TVFC and ASN Provider achievements: Suggested Activity
- Implement incentives for provider sites that reach
vaccination coverage rate goals; and
- Implement incentives to recognize sites during national
observances(i.e.NIIW,NIAM,and NNW)
3.3. PROVIDER EDUCATION
3.3.01 Provide a training for TVFC and ASN providers within the Suggested
LHD Grantee's jurisdiction on the policies outlined in the Activity
TVFC and ASN Provider Manual and recommended
procedures for implementing them. These include:
- procedures for following storage and handling guidelines;
- procedures for vaccine management;
- procedures for using the DSHS vaccine management
system(VAOS);
- procedures for vaccine borrowing;
- procedures for other compliance guidelines;
- appropriate reporting of vaccine adverse events;
- appropriate routine and emergency vaccine storage and
handling plans;and
- meeting the federal requirement that the most current
Vaccine Information Statements (VIS) available at
https://www.cdc.gov/vaccines/hcp/vis/index.html
distributed to patients prior to patient vaccination
DSHS Contract No.H S000109900001 Page 16 of 33
Amendment 4
DocuSign Envelope ID:B2CCD95C-F3AB-4BF8-9618-4AC2AA9A5FD1
3.3.02 Notify providers of TVFC and ASN updates and changes to Standard
program policies and procedures. (Universal)
Notify TVFC/ASN providers of the following:
- CDC and DSHS Announcements;
- TVFC/ASN Trainings;
- Vaccine storage and handling policy updates;
- Vaccine ordering changes; and
- Vaccine choice
3.3.03 Educate and assist TVFC and ASN providers on a quarterly Standard
basis with Provider Choice, as necessary (Universal)
3.3.04 Inform TVFC and ASN providers of the most up-to-date, Standard
DSHS-produced immunization information for their offices (Universal)
3.3.05 Identify TVFC and ASN providers experiencing high volumes Required Activity
of vaccine loss and develop process improvements/trainings
aimed at reducing the amount of vaccine loss (including wasted
and expired) in their clinics
3.4. PROVIDER VACCINE MANAGEMENT
3.4.01 Utilize the DSHS Vaccine Allocation and Ordering System Required Activity
(VAOS) reports and other provider submitted reports to
perform 100% of quality assurance reviews on the following
TVFC and ASN:
- monthly biological reports (doses administered and current
inventory);
-vaccine orders;
-temperature log; and
- clinic hours of operation from TVFC and ASN providers in
LHD Grantee's jurisdiction. Address all issues identified
during review
3.4.02 Transfer vaccines that cannot be stored within provider Standard
offices (ex. accidental large orders) and vaccines (Universal)
approaching expiration between providers in LHD Grantee's
jurisdiction for immediate use
DSHS Contract No.HHS000109900001 Page 17 of 33
Amendment 4
DocuSign Envelope ID:B2CCD95C-F3AB-4BF8-9618-4AC2AA9A5FD1
3.4.03 Ensure provider participation in vaccine ordering and Standard
inventory management using the Vaccine Allocation and (Universal)
Ordering System(VAOS):
- Educate providers regarding vaccine ordering policies; and
-Train providers to use VAOS for inventory and order entry
3.4.04 Assist TVFC and ASN providers in LHD Grantee's Standard
jurisdiction on the maintenance of appropriate vaccine stock (Universal)
levels. Activities under this requirement shall be conducted in
accordance with the DSHS Immunization Contractor's Guide
for Local Health Departments and the current TVFC and ASN
Program Operations Manual for Responsible Entities
3.4.05 Train TVFC and ASN providers within LHD Grantee's Standard
jurisdiction to ensure that expired and spoiled/wasted (Universal)
vaccines are appropriately identified and entered into the
Vaccine Allocation and Ordering System (VAOS).
Train providers to complete returns to CDC's centralized
distributor within six months of product expiration
3.4.06 Ensure that 100% of TVFC providers within the LHD Required Activity
Grantee's jurisdiction complete the annual influenza pre-book
survey
3.5. PROVIDER QUALITY ASSURANCE
3.5.01 Utilize the CDC Provider Education Assessment and Reporting Required Activity
(PEAR) system and CDC Immunization Quality Improvement for
Providers (IQIP) database to document TVFC compliance and
IQIP site visits for all subcontracted clinics and non-LHD
Grantee's clinics (as applicable)
3.5.02 Utilize the CDC PEAR system and directly enter data into PEAR Required Activity
to document TVFC unannounced storage and handling visits to a
minimum of 10% of providers within the LHD Grantee's
jurisdiction
3.5.03 Utilize the CDC PEAR system and directly enter data into PEAR Required Activity
to document TVFC Unannounced Storage and Handling Visits,
Compliance Visits and other visits conducted at TVFC provider
offices
3.5.04 Complete and document 100% of the follow-up activities for Required Activity
TVFC quality assurance visits within required timeframes
DSHS Contract No.HHS000109900001 Page 18 of 33
Amendment 4
DocuSign Envelope ID:B2CCD95C-F3AB-4BF8-9618-4AC2AA9A5FD1
3.5.05 Utilize Texas Immunization Registry or DSHS-provided coverage Required Activity
rates to assess immunization practices and coverage rates for all
subcontracted entities and non-LHD Grantee's clinics (as
applicable)
3.5.06 Review 100%of re-enrollment applications from TVFC and ASN Required Activity
providers in your jurisdiction by the DSHS specified deadline
3.5.07 Ensure that expired, wasted, and unaccounted-for vaccines Standard
(excluding flu) do not exceed 5% in TVFC provider clinics within (Universal)
the LHD Grantee's jurisdiction
3.5.08 Review monthly reports to ensure data quality. This includes: Required Activity
- Identify sites that have not administered or ordered vaccine in
the previous six months. Conduct a discussion and develop a
plan of action;
- Identify sites that are suspended to ensure 90 days is not
exceeded; and
- Ensure enrollment and withdrawal forms are submitted
correctly and on time to the PHR staff
3.5.09 Review submitted reports to ensure data quality. This includes: Suggested
Activity
- Quarterly, review 25% of enrolled sites to ensure contacts are
listed correctly in Syntropi; and
- Quarterly, review 25% of enrolled sites and provide education
for the Vaccine borrowing and Vaccine transfer forms
3.5.10 Review monthly data logger reports for 25% of providers in LHD Suggested
Grantee's jurisdiction to validate the accuracy of provider- Activity
submitted monthly temperature reporting forms
3.5.11 Review monthly data logger reports to validate the accuracy of Standard
provider-submitted monthly temperature reporting forms for all (Conditional)
providers within LHD Grantee's jurisdiction who experience a
vaccine loss as a result of temperature excursions
3.5.12 Conduct a monthly review of 10% of randomly selected providers Suggested
in LHD Grantee's jurisdiction to identify vaccine loss report forms Activity
that were completed in VAOS but were not submitted
3.5.13 Conduct a quarterly review of 25% of providers in LHD Grantee's Suggested
jurisdiction to identify those that have adjusted more than 10% of Activity
their vaccine inventory
3.5.14 Conduct a quarterly review of 25%of providers in LHD Grantee's Suggested
jurisdiction to ensure the reported patient population matches the Activity
number of doses ordered
DSHS Contract No.HHS000109900001 Page 19 of 33
Amendment 4
DocuSign Envelope ID: B2CCD95C-F3AB-4BF8-9618-4AC2AA9A5FD1
3.5.15 Utilize the CDC IQIP database and directly enter data to document Required
IQIP follow-ups visits conducted at TVFC provider offices Activity
3.6. PROVIDER ACCOUNTABILITY
3.6.01 Track, report and follow up on vaccine fraud and abuse cases Standard
(Universal)
3.6.02 Complete program evaluation activities with TVFC and ASN Required
providers to address issues identified as noncompliance issues Activity
For all TVFC providers, document corrective action plans in
the CDC PEAR system as a contact
3.7. RE STAFF EDUCATION
3.7.01 Train LHD Grantee's staff to follow the policies and procedures Required Activity
outlined in the TVFC &ASN Program Operations Manual for
Responsible Entities. Provide training on TVFC and ASN
requirements and updates (as described in the TVFC &ASN
Program Operations Manual for Responsible Entities) annually at a
minimum
3.7.02 For personnel identified by DSHS, attend and/or complete the Required Activity
following trainings:
- CDC Immunization Trainings;
- TVFC/ASN Annual Trainings;
- Annual Responsible Entity Training; and
- Public Health Region(PHR) Trainings
3.7.03 Ensure that the TVFC &ASN Coordinator conducts quality Suggested Activity
assurance on 10% of the temperature recording logs that were
reviewed by their staff each quarter
3.8. RE COMPLIANCE
3.8.01 Comply with the current DSHS Immunization Contractor's Standard
Guide for Local Health Departments and the TVFC and ASN (Universal)
Operations Manual for Responsible Entities
3.8.02 Receive regional approval for any vaccine transfers and Standard
document those transfers in VAOS within 24 hours of the (Universal)
transfer occurring
DSHS Contract No.HHS000109900001 Page 20 of 33
Amendment 4
DocuSign Envelope ID: B2CCD95C-F3AB-4BF8-9618-4AC2AA9A5FD1
3.8.03 Address general inquiries by providers about the TVFC/ASN Standard
Program, and ensure timely follow-up on requests for (Universal)
information
3.8.04 Ensure that providers within LHD Grantee's jurisdiction are Required Activity
adhering to the vaccine borrowing procedures outlined in the
TVFC and ASN Provider Manual
Report the number of borrowing forms submitted by quarter in
the Immunization Inter-Local Agreement(ILA) Quarterly
Report
3.9. RE EMERGENCY RESPONSE
3.9.01 Communicate the importance of an Emergency Vaccine Storage Standard (Universal)
and Handling Plan to all clinics in the LHD Grantee's
jurisdiction. Provide technical assistance to support the
successful activation of each clinic's Emergency Vaccine
Storage and Handling Plan
3.9.02 Transfer, accept, and store TVFC and ASN vaccines from Standard(Universal)
clinics in the LHD Grantee's jurisdiction if there is a failure in
the clinic's Emergency Vaccine Storage and Handling Plan
3.9.03 Be prepared to pack and ship vaccine to other sites, as directed Required Activity
by the DSHS Immunization Unit
4. EPIDEMIOLOGY & SURVEILLANCE
4.1. PERINATAL HEPATITIS B CASE IDENTIFICATION
4.1.01 Conduct identification and case management of perinatal Standard(Universal)
hepatitis B cases
4.1.02 Determine the number of newborns that do not receive the Required Activity
first dose of the hepatitis B vaccine and/or HBIG and work
with those facilities to ensure all at-risk infants receive the
hepatitis B vaccine series and HBIG within 12 hours of birth
4.1.03 Ensure timely follow-up and reporting of case status of Required Activity
possible moms as reported by DSHS within 2 weeks of
receipt of report
DSHS Contract No.HHS000109900001 Page 21 of 33
Amendment 4
DocuSign Envelope ID:B2CCD95C-F3AB-4BF8-9618-4AC2AA9A5FD1
4.2. PERINATAL HEPATITIS B CASE MANAGEMENT
4.2.01 Contact and provide case management to 100% of hepatitis Required Activity
B surface antigen-positive pregnant women identified, along
with their infants and contacts
4.3. PERINATAL HEPATITIS B REPORTING
4.3.01 For all cases documented as 'lost-to-follow-up' on the Required Activity
Perinatal Hepatitis B case management form, report the
number and types of attempted activities performed in
locating the mother or guardian of the infant to the DSHS
Immunization Unit on the Perinatal Hepatitis B case
management form
4.4. PERINATAL HEPATITIS B EDUCATION
4.4.01 Require Perinatal Hepatitis B Case Manager to attend the Required Activity
biannual conference
4.4.02 Conduct educational training for hospitals, prenatal care Required Activity
providers,pediatricians, birthing facilities, and other
healthcare providers/facilities within the Grantee's
jurisdiction, to increase identification, timely reporting, and
appropriate case management of pregnant woman with
hepatitis and their infants and contacts.
4.4.03 Work with partners, as appropriate, to ensure coordination Standard(Universal)
of activities aimed at preventing perinatal hepatitis B
transmission
4.5. DISEASE SURVEILLANCE
4.5.01 Complete investigation and document at least 90% of Required Activity
confirmed or probable reportable vaccine-preventable
disease (VPD) cases within thirty(30)days of initial
report to public health
4.5.02 Adhere to the DSHS Emerging and Acute Infectious Standard(Universal)
Disease Guidelines and current Epi Case Criteria Guide in
conducting all activities
DSHS Contract No.HHS000109900001 Page 22 of 33
Amendment 4
DocuSign Envelope ID:B2CCD95C-F3AB-4BF8-9618-4AC2AA9A5FD1
4.5.03 Ensure all new VPD surveillance staff attend'Introduction Required Activity
to NBS'training and complete the certification process in
order to gain access to the NBS system
4.5.04 Complete all data entry into the Texas National Electronic Standard (Universal)
Disease Surveillance System (NEDSS) Base System
(NBS) following the NBS Data Entry Guidelines
4.5.05 Routinely review and follow up on all VPD laboratory Standard (Universal)
reports received, including electronic lab reports (ELRs)
generated through NBS in a timely fashion
4.5.06 Verify and enter complete vaccination history in NBS on Required Activity
all VPD investigations with case status of confirmed or
probable. Complete vaccination history can be assessed
through the Texas Immunization Registry,provider
offices, school records, and/or patient records
4.5.07 Initiate vaccine-based disease control activities by Standard (Universal)
identifying population in need of a vaccination response
and requesting vaccination services for that population by
contacting the DSHS Vaccine-Preventable Disease (VPD)
Surveillance Team Lead
4.6. DISEASE SURVEILLANCE EDUCATION
4.6.01 Educate physicians, laboratories, hospitals, schools, child- Suggested Activity
care staff, and other health providers on VPD reporting
requirements
4.7. NEEDS ASSESSMENT
4.7.01 Conduct a community needs assessment to identify gaps Required Activity
in coverage rates or"pockets of need" for immunization
activities.
• Select an area of focus from the list of measurements
provided in the Metrix or obtain approval from
Immunization Unit epis for an alternate area of focus.
• Create an assessment plan, collect data, gather
stakeholder feedback, and analyze the information
4.7.02 Design an intervention to address the need identified in Suggested Activity
4.7.01
DSHS Contract No.HHS000109900001 Page 23 of 33
Amendment 4
DocuSign Envelope ID:B2CCD95C-F3AB-4BF8-9618-4AC2AA9A5FD1
PROVIDING A VACCINE SAFETY NET
5.1. CLINIC ENROLLMENT
5.1.01 Enroll all eligible LHD clinics into the TVFC and ASN Required
Programs as providers Activity
5.1.02 Provide immunization services according to national Standard
standards for immunization practices for infants, children, (Universal)
adolescents, adults, and healthcare workers. LHD clinics
will comply with the National Childhood Vaccine Injury
Act of 1986
5.2. CLINIC STAFF TRAINING
5.2.01 Train all clinic staff on the policies outlined in the TVFC Required
and ASN Provider Manual and LHD procedures for Activity
implementing them. These include:
- procedures for following storage and handling guidelines;
- procedures for vaccine management; and
- procedures for using the DSHS vaccine management
system (VAOS)procedures for other compliance
guidelines
5.2.02 Develop clinic staff education requirements. Ensure that Required
persons who administer vaccines and staff that are involved Activity
in the vaccine administration process (including those who
screen immunization records and administer vaccines)to
follow Advisory Committee on Immunization Practices
(ACIP) standards for children and adults and are
knowledgeable on immunizations and immunization practices
This can be accomplished by having staff complete the most
current CDC Pink Book(Epidemiology and the Prevention of
Vaccine Preventable Diseases)training and appropriate
Vaccine Education Online (VEO) modules
5.2.03 Develop eligibility screening and documentation policy for Required
all LHD clinics. Provide training to all staff on appropriate Activity
screening and documentation for TVFC eligibility to ensure
TVFC vaccine is administered only to TVFC-eligible
children. Implement policy and plan for routine adherence to
eligibility policies
DSHS Contract No.HHS000109900001 Page 24 of 33
Amendment 4
DocuSign Envelope ID:B2CCD95C-F3AB-4BF8-9618-4AC2AA9A5FD1
5.2.04 Develop and implement a policy on the use of the Texas Required
Immunization Registry. Train LHD staff on conducting Activity
client searches in the Texas Immunization Registry and how
to effectively enter client demographic and immunization
information
5.3. CLINIC IMMUNIZATION PRACTICES
5.3.01 Comply with current applicable state and federal standards, Standard
policies and guidelines for clinics (Universal)
5.3.02 Provide vaccines regardless of residency or ability to pay Standard
(Universal)
5.3.03 Adhere to clinical records retention schedule Standard
(Universal)
5.3.04 Explain the benefits of a"medical home" and assist the Standard
parent/guardian in obtaining or identifying the child's (Universal)
medical home
5.3.05 Discuss the next ACIP-recommended vaccines and refer the Standard
client to a medical home to complete the vaccination series (Universal)
5.3.06 Maintain a list of current providers within the LHD's Standard
jurisdiction who accept children on Medicaid or CHIP and (Universal)
make this list available to clinic clients and families as needed
5.3.07 Refer uninsured clients to Medicaid or the Children's Health Standard
Insurance Program (CHIP) as appropriate (Universal)
5.3.08 Ensure that all ACIP-recommended vaccines are routinely Standard
available and offered to TVFC patients (Universal)
5.3.09 Ensure that all vaccines listed on the ASN vaccine formulary Standard
are available and offered to eligible adult patients (Universal)
5.3.10 Establish"standing orders" for vaccination in LHD Grantee's Required
clinics that are consistent with legal requirements for standing Activity
orders (including, but not limited to, those found in the Texas
Medical Practice Act)
5.3.11 Search for the client's immunization history at every client Standard
encounter. Compare all immunization histories (Texas (Universal)
Immunization Registry, TWICES or EMR system, validated
patient-held records, clinic medical record) and enter into the
Texas Immunization Registry all historical immunizations not
in the Registry at every client encounter. Review the client's
record for vaccines due and overdue according to the CDC
recommended schedules at:
https://www.cdc.gov/vaccines/schedules/index.html
DSHS Contract No.HHS000109900001 Page 25 of 33
Amendment 4
DocuSign Envelope ID: B2CCD95C-F3AB-4BF8-9618-4AC2AA9A5FD1
5.3.12 Offer updated Immunization History Report to the client or Standard
client's parent or guardian at every client encounter (Universal)
5.3.13 Follow and explain recommended guidelines for obtaining Standard
and submitting ImmTrac2 consent forms according to the (Universal)
instructions found at
http://www.dshs.texas.gov/immunize/immtrac/forms.shtm
5.3.14 Report to the Texas Immunization Registry all immunizations Standard
administered to consented children(younger than 18 years of (Universal)
age) and consented adults in LHD Grantee's clinics, either by
entering data directly into the Registry or through electronic
data exchange via TWICES or an electronic medical record
(EMR) system
5.3.15 Verbally and with DSHS-produced literature, inform parents Standard
at LHD Grantee's clinics about the Texas Immunization (Universal)
Registry, the benefits of inclusion in the Registry, and the
importance of maintaining a complete immunization history in
the Registry
5.3.16 Update all demographic information, including address, Standard
email, and telephone number, at every client encounter in (Universal)
EMR and the Texas Immunization Registry
5.3.17 Verbally educate patients and parents/guardians about the Standard
benefits and risks of vaccination and distribute DSHS (Universal)
educational materials, as applicable, as part of this
conversation
5.3.18 Follow only medically supportable contraindications to Standard
vaccination (Universal)
5.3.19 Provide immunization services at times other than 8 am to 5 Required
pm, Monday through Friday, at least once per month Activity
5.3.20 Institute infection control practices, including effective hand Standard
washing and management of hazardous waste (Universal)
5.3.21 Maintain confidentiality of client information Standard
(Universal)
5.3.22 Recommend the simultaneous administration of all needed Standard
vaccines for the patient (Universal)
5.3.23 Implement clinic policy on screening and documentation of Standard
eligibility for TVFC vaccines. The policy must be consistent (Universal)
with the TVFC requirements outlined in the current TVFC and
ASN Provider Manual
5.3.24 Participate in public health emergencies and exercises that Suggested
may require vaccine administration to the public or first Activity
responders
DSHS Contract No.HHS00010990000I Page 26 of 33
Amendment 4
DocuSign Envelope ID:B2CCD95C-F3AB-4BF8-9618-4AC2AA9A5FD1
5.3.25 Conduct outreach activities to raise the immunization Suggested
coverage levels of uninsured adults by visiting sites such as Activity
homeless shelters,halfway houses, day labor sites or other
locations
5.3.26 Coordinate with community vaccinators to conduct annual Suggested
employee-based vaccination clinics for influenza vaccine Activity
administration
5.4. CLINIC VACCINE MANAGEMENT
5.4.01 Ensure that all expired and spoiled/wasted vaccines are Required Activity
appropriately identified and entered into the Vaccine
Allocation and Ordering System (VAOS) for the LHD
Grantee's clinics
5.4.02 Submit returns for all vaccines distributed via CDC's Standard
centralized distributor back to the centralized distributor for (Universal)
returns processing
5.5. CLINIC QUALITY ASSURANCE
5.5.01 Ensure that appropriate routine and emergency vaccine Required Activity
storage and handling plans are in place at each of the LHD
Grantee clinic locations
5.5.02 Ensure that expired, wasted, and unaccounted-for vaccines Standard
(excluding flu)do not exceed 5 percent in LHD Grantee's (Universal)
clinics
5.6. CLINIC REPORTING
5.6.01 Conduct timely reporting of monthly clinic activities by Required Activity
recording vaccine inventory, doses administered,
temperature logs and other reportable activities by the 5th of
each month as described in the TVFC/ASN Provider
Manual
5.6.02 Report all notifiable conditions as specified in the DSHS Standard(Universal)
Immunization Contractor's Guide for Local Health
Departments
5.6.03 Report all vaccine adverse events as specified in the DSHS Standard(Universal)
Immunization Contractor's Guide for Local Health
Departments
DSHS Contract No.HHS000109900001 Page 27 of 33
Amendment 4
DocuSign Envelope ID:B2CCD95C-F3AB-4BF8-9618-4AC2AA9A5FD1
5.6.04 Report the number of unduplicated underinsured clients Required Activity
and the number of doses administered to underinsured
children monthly as specified in the DSHS Immunization
Contractor's Guide for Local Health Departments
5.6.05 Conduct monthly reporting of doses administered to Required Activity
women veterans, as required in the ASN Program
INCREASING USE OF THE TEXAS IMMUNIZATION REGISTRY
6.1. TEXAS IMMUNIZATION REGISTRY OUTREACH FOR IMMUNIZATION RECORDS
6.1.01 Conduct Texas Immunization Registry outreach to Suggested
organizations regarding missing vaccinations for children and Activity
adults for whom consent has been granted but who do not have
complete immunization records
6.2. TEXAS IMMUNIZATION REGISTRY OUTREACH FOR PATIENT CONSENTS
6.2.01 Conduct activities aimed at increasing the consent rate for all Suggested
age groups, including adults and individuals identified as Activity
recently moved in-state
6.2.02 Conduct at least twelve (12) outreach and educational Required Activity
activities focused on 18-year-olds in high schools and
colleges/universities in LHD Grantee's jurisdiction
6.3. TEXAS IMMUNIZATION REGISTRY OUTREACH TO USERS
6.3.01 Conduct outreach to existing Registry users who have not Required Activity
logged into the Registry in the last 90 days
6.3.02 Provide orientation to all new Texas Immunization Registry Suggested
organizations within the LHD Grantee's jurisdiction at least Activity
once a year and maintain documentation of all technical
assistance provided (e.g., telephone logs)
Provide education and training on the effective use of the
Texas Immunization Registry according to the Guidelines for
Increasing the Use of the Texas Immunization Registry
Identify and assist newly registered providers and new users
reporting to the Texas Immunization Registry
DSHS Contract No.HHS000109900001 Page 28 of 33
Amendment 4
DocuSign Envelope ID: B2CCD95C-F3AB-4BF8-9618-4AC2AA9A5FD1
6.4. TEXAS IMMUNIZATION REGISTRY USER EDUCATION
6.4.01 Provide education, training, and technical assistance to Suggested Activity
promote the effective use of the Texas Immunization
Registry by organizations
6.4.02 Identify and assist providers to establish electronic Required Activity
affirmation of consent
6.5. TEXAS IMMUNIZATION REGISTRY PROMOTION
6.5.01 Promote the use of the Texas Immunization Registry to Required
organizations within the LHD Grantee's jurisdiction that are Activity
not currently enrolled in the Registry. Identify all providers
who administer vaccine in awardee's jurisdiction, including
both pediatric and adult immunization providers. Educate them
on their statutory requirement to report immunizations and on
the enrollment process
6.5.02 Provide education and technical assistance to birth registrars on Suggested
the effective use of the Texas Immunization Registry Activity
6.5.03 Collaborate with prenatal healthcare providers,birth registrars, Suggested
hospital staff,pediatricians, and other entities to educate Activity
parents, expectant parents, and providers about the Texas
Immunization Registry and the benefits of participation. This
includes the dissemination of DSHS educational materials as
appropriate
6.6. TEXAS IMMUNIZATION REGISTRY PROGRAM QUALITY IMPROVEMENT
6.6.01 Review the monthly Provider Activity Report(PAR)to Required Activity
identify organizations who are inactive or not routinely
submitting immunization data or adding consented clients.
Prioritize these organizations for outreach activities
6.6.02 Review the quarterly Consent Accepted Rate Evaluation Required Activity
(CARE)report to target organizations with largest client
volume and/or lowest consent acceptance rate. Prioritize these
organizations for outreach activities
DSHS Contract No.HHS000109900001 Page 29 of 33
Amendment 4
DocuSign Envelope ID:B2CCD95C-F3AB-4BF8-9618-4AC2AA9A5FD1
6.6.03 Conduct a minimum of 60 Texas Immunization Registry Required Activity
organization quality improvement assessments per FTE each
year as described in the Guidelines for Increasing the Use of
the Texas Immunization Registry. (For jurisdictions with less
than 60 orgs, conduct quality improvement assessment visits to
100% of your orgs)
L EDUCATION AND PARTNERSHIPS
7.1 PUBLIC EDUCATION
7.1.01 Inform and educate the public about vaccines and vaccine- Required
preventable diseases Activity
7.1.02 Inform the general public about the TVFC and ASN Programs Required
and the eligibility criteria for qualifying for the programs Activity
7.2 PROVIDER EDUCATION
7.2.01 Educate and update providers on the most current ACIP Suggested
recommendations for all age groups Activity
7.2.02 Inform and highly recommend to the medical community and Suggested
local providers within the LHD Grantee's jurisdiction the most Activity
current Centers for Disease Control and Prevention(CDC)
Epidemiology and Prevention of Vaccine-Preventable Disease
(EPI-VAC) training(https://www.cdc.gov/vaccines/ed/webinar-
epv/index.html).
The most current"Pink Book,"titled Epidemiology and
Prevention of Vaccine-Preventable Diseases, can be found on the
CDC website at
http://www.cdc.gov/vaccines/pubs/pinkbooldindex.html
7.2.03 Provide information to community healthcare employers Suggested
(hospitals, clinics, doctor offices, long-term care facilities) about Activity
the importance of vaccination of healthcare workers
7.2.04 Provide training relating to Standards for Child and Adolescent Suggested
Immunization Practices and Standards for Adult Immunization Activity
Practices to all immunization providers within LHD Grantee's
jurisdiction
DSHS Contract No.HHS000109900001 Page 30 of 33
Amendment 4
DocuSign Envelope ID:B2CCD95C-F3AB-4BF8-9618-4AC2AA9A5FD1
7.2.05 Provide training opportunities and/or resources to assist Required
immunization providers in communicating with patients and/or Activity
parents (e.g., making a strong recommendation, addressing
vaccine hesitancy, etc.)
7.3 STAFF EDUCATION
7.3.01 Work to ensure that all Immunization Program Grantee staff are Standard
knowledgeable about vaccines and VPDs (Universal)
7.3.02 Develop and implement a written communications and Required Activity
customer service plan for Grantee's staff to ensure customers
receive consistent, correct immunization information and
services in a courteous and friendly manner on a timely basis
7.3.03 Educate healthcare workers on the importance of keeping Required Activity
themselves up-to-date with the vaccine schedule
7.4 COALITION BUILDING
7.4.01 Appoint an immunization coalition coordinator Required Activity
7.4.02 Attend and participate in required coalition trainings sponsored Required Activity
by DSHS
7.4.03 Develop and maintain a planning group with the goal of Suggested Activity
sustaining a coalition
7.4.04 Engage and recruit community groups and immunization Suggested Activity
stakeholders into a coalition
7.4.05 Facilitate and host coalition meetings Suggested Activity
7.4.06 Participate in monthly calls to provide updates on coalition Required Activity
collaboration activities
7.4.07 Provide signed letters of agreement and other documentation of Suggested Activity
commitment to participate in coalition
7.4.08 Document communications, group meetings, and planning of Required Activity
activities that promote the best practices identified in contract
agreement(documents are to be accessible during site visits)
7.5 COMMUNITY PARTNERSHIP
DSHS Contract No.HHS000109900001 Page 31 of 33
Amendment 4
DocuSign Envelope ID: B2CCD95C-F3AB-4BF8-9618-4AC2AA9A5FD1
7.5.01 Plan and implement community education activities and Required Activity
partnerships aimed at improving and sustaining immunization
coverage levels
7.5.02 Conduct outreach and collaborative activities with American Required Activity
Indian tribes, if applicable
7.5.03 Participate in at least one collaborative meeting concerning Required Activity
tribal health issues, concerns, or needs with American Indian
tribal members, if applicable
7.5.04 Coordinate educational and other activities with local Women, Suggested Activity
Infants, and Children(WIC)programs to ensure that children
participating in WIC are screened and referred to their"medical
home"for vaccination using a documented immunization
history in accordance with the Standards for Child and
Adolescent Immunization Practices
7.5.05 Offer educational opportunities to all WIC Programs in the Suggested Activity
service area, including information about online and satellite-
broadcast continuing education opportunities from the CDC
Continuing Education website at
https://www.cdc.gov/vaccines/ed/index.html
7.5.06 Engage in education and partnerships aimed at reducing or Required Activity
eliminating coverage disparities by race, ethnicity, and
socioeconomic status
7.5.07 Maintain a contact list of providers, hospitals, schools, child- Required Activity
care facilities, social service agencies, and community groups
involved in promoting immunizations and reducing vaccine-
preventable diseases
7.5.08 Participate in special initiatives as directed by the DSHS Required Activity
Immunization Unit
7.5.09 Implement the DSHS Immunization Ambassador Program Required Activity
throughout Grantee's jurisdiction
7.6 STAKEHOLDER ENGAGEMENT
7.6.01 Attend all Texas Immunizers and Stakeholders Working Required Activity
Groups (TISWG)and other designated stakeholder meetings
(these meetings can be attended remotely)
7.6.02 Host at least 1 immunization stakeholder meeting per Suggested Activity
quarter(4 per contract year)
DSHS Contract No.HHS000109900001 Page 32 of 33
Amendment 4
DocuSign Envelope ID: B2CCD95C-F3AB-4BF8-9618-4AC2AA9A5FD1
7.7 MEDIA CAMPAIGNS
7.7.01 Distribute ASN information and educational materials at Required Activity
venues and clinics that serve eligible adults
7.7.02 Distribute TVFC information and educational materials at Required Activity
venues that parents of TVFC-eligible children might frequent
7.7.03 Participate,when directed, in statewide media campaigns by Required Activity
distributing DSHS-developed and produced public service
announcements and materials to local television and radio
stations, newspapers,parent publications, university
newspapers, high school newspapers, and neighborhood
newspapers
7.7.04 Promote www.ImmunizeTexas.com,the Immunization Unit's Required Activity
website; and any other Immunization Unit newsletters to
providers in the LHD Grantee's jurisdiction
7.7.05 Use national immunization observances as opportunities to Required Activity
conduct specific education and promotional activities to give
emphasis to the importance and benefits of vaccines: National
Infant Immunization Week(NIIW),National Immunization
Awareness Month(NIAM), and National Influenza
Immunization Week(NIIW)
7.7.06 Share available federal, state, and/or local adolescent Required Activity
vaccination coverage and/or vaccine-uptake-related data with
partner organizations, adolescent immunization providers,
and other stakeholders
DSHS Contract No.HHS000109900001 Page 33 of 33
Amendment 4
DocuSign
Certificate Of Completion
Envelope Id:B2CCD95CF3AB4BF896184AC2AA9A5FD1 Status: Sent
Subject:Please DocuSign:HHS000109900001 -City of Port Arthur-FY23 IMM LOCALS-A-4
Source Envelope:
Document Pages:33 Signatures: 1 Envelope Originator:
Certificate Pages:5 Initials:0 CMS Internal Routing Mailbox
AutoNav:Enabled 11493 Sunset Hills Road
Envelopeld Stamping:Enabled #100
Time Zone:(UTC-06:00)Central Time(US&Canada) Reston,VA 20190
CMS.InternalRouting@dshs.texas.gov
IP Address: 167.137.1.16
Record Tracking
Status: Original Holder:CMS Internal Routing Mailbox Location:DocuSign
4/22/2022 8:58:37 AM CMS.InternalRouting@dshs.texas.gov
Signer Events Signature Timestamp
Judith Smith '—DotulS' tr
y:
Sent:4/22/2022 9:05:41 AM
/
judith.smith@portarthurtx.gov Sol& Viewed:4/22/2022 9:20:18 AM
`—F046504AE030471...
Director of Health Services Signed:4/22/2022 9:27:52 AM
City of Port Arthur
Security Level:Email,Account Authentication Signature Adoption:Pre-selected Style
(None) Signed by link sent to judith.smith@portarthurtx.gov
Using IP Address: 71.40.211.219
Electronic Record and Signature Disclosure:
Accepted:4/22/2022 9:20:18 AM
ID:9a15f480-daa4-4c74-b3ff-5400ec31e878
Ron Burton,City Manager Sent:4/22/2022 9:27:56 AM
ron.burton@portarthurtx.gov
City Manager
City of Port Arthur
Security Level:Email,Account Authentication
(None)
Electronic Record and Signature Disclosure:
Accepted:4/20/2022 2:42:18 PM
ID:ae83aa89-6f00-4aad-acc6-6a3f917b8e6c
Susana Garcia
Susana.Garcia@dshs.texas.gov
Security Level:Email,Account Authentication
(None)
Electronic Record and Signature Disclosure:
Accepted:4/22/2022 8:18:37 AM
ID:fe6a12c5-5f02-48fd-94ec-b3a8fd3848df
Patty Melchior
Patty.Melchior@dshs.texas.gov
Security Level:Email,Account Authentication
(None)
Electronic Record and Signature Disclosure:
Accepted:4/22/2022 8:43:50 AM
ID: 1e63b14c-6ef3-4071-ab11-9fc7e72060ab
Imelda Garcia
imeldam.garcia@dshs.texas.gov
Security Level:Email,Account Authentication
(None)
Electronic Record and Signature Disclosure:
Signer Events Signature Timestamp
Accepted:7/6/2021 8:08:45 AM
ID: 1a6909aa-b026-45a9-be9f-4240c2e32ff9
In Person Signer Events Signature Timestamp
Editor Delivery Events Status Timestamp
Agent Delivery Events Status Timestamp
Intermediary Delivery Events Status Timestamp
Certified Delivery Events Status Timestamp
Carbon Copy Events Status Timestamp
CMS Internal Routing
cms.internalrouting@dshs.texas.gov
Security Level: Email,Account Authentication
(None)
Electronic Record and Signature Disclosure:
Not Offered via DocuSign
Beatrice Avalos
beatrice.avalos@dshs.texas.gov
Security Level:Email,Account Authentication
(None)
Electronic Record and Signature Disclosure:
Not Offered via DocuSign
Witness Events Signature Timestamp
Notary Events Signature Timestamp
Envelope Summary Events Status Timestamps
Envelope Sent Hashed/Encrypted 4/22/2022 9:05:42 AM
Payment Events Status Timestamps
Electronic Record and Signature Disclosure
Electronic Record and Signature Disclosure created on:9/14/2020 7:10:18 PM
Parties agreed to:Judith Smith,Ron Burton,City Manager,Susana Garcia,Patty Melchior,Imelda Garcia
ELECTRONIC RECORD AND SIGNATURE DISCLOSURE
From time to time, DSHS Contract Management Section (we, us or Company) may be required
by law to provide to you certain written notices or disclosures. Described below are the terms
and conditions for providing to you such notices and disclosures electronically through the
DocuSign system. Please read the information below carefully and thoroughly, and if you can
access this information electronically to your satisfaction and agree to this Electronic Record and
Signature Disclosure(ERSD),please confirm your agreement by selecting the check-box next to
`I agree to use electronic records and signatures' before clicking `CONTINUE' within the
DocuSign system.
Getting paper copies
At any time, you may request from us a paper copy of any record provided or made available
electronically to you by us. You will have the ability to download and print documents we send
to you through the DocuSign system during and immediately after the signing session and, if you
elect to create a DocuSign account, you may access the documents for a limited period of time
(usually 30 days) after such documents are first sent to you. After such time, if you wish for us to
send you paper copies of any such documents from our office to you, you will be charged a
$0.00 per-page fee. You may request delivery of such paper copies from us by following the
procedure described below.
Withdrawing your consent
If you decide to receive notices and disclosures from us electronically, you may at any time
change your mind and tell us that thereafter you want to receive required notices and disclosures
only in paper format. How you must inform us of your decision to receive future notices and
disclosure in paper format and withdraw your consent to receive notices and disclosures
electronically is described below.
Consequences of changing your mind
If you elect to receive required notices and disclosures only in paper format, it will slow the
speed at which we can complete certain steps in transactions with you and delivering services to
you because we will need first to send the required notices or disclosures to you in paper format,
and then wait until we receive back from you your acknowledgment of your receipt of such
paper notices or disclosures. Further, you will no longer be able to use the DocuSign system to
receive required notices and consents electronically from us or to sign electronically documents
from us.
All notices and disclosures will be sent to you electronically
Unless you tell us otherwise in accordance with the procedures described herein,we will provide
electronically to you through the DocuSign system all required notices, disclosures,
authorizations, acknowledgements, and other documents that are required to be provided or made
available to you during the course of our relationship with you. To reduce the chance of you
inadvertently not receiving any notice or disclosure, we prefer to provide all of the required
notices and disclosures to you by the same method and to the same address that you have given
us. Thus, you can receive all the disclosures and notices electronically or in paper format through
the paper mail delivery system. If you do not agree with this process, please let us know as
described below. Please also see the paragraph immediately above that describes the
consequences of your electing not to receive delivery of the notices and disclosures
electronically from us.
How to contact DSHS Contract Management Section:
You may contact us to let us know of your changes as to how we may contact you electronically,
to request paper copies of certain information from us, and to withdraw your prior consent to
receive notices and disclosures electronically as follows:
To contact us by email send messages to: alison.joffrion@hhsc.state.tx.us
To advise DSHS Contract Management Section of your new email address
To let us know of a change in your email address where we should send notices and disclosures
electronically to you, you must send an email message to us at alison.joffrion@hhsc.state.tx.us
and in the body of such request you must state: your previous email address, your new email
address. We do not require any other information from you to change your email address.
If you created a DocuSign account, you may update it with your new email address through your
account preferences.
To request paper copies from DSHS Contract Management Section
To request delivery from us of paper copies of the notices and disclosures previously provided
by us to you electronically, you must send us an email to alison.joffrion@hhsc.state.tx.us and in
the body of such request you must state your email address, full name, mailing address, and
telephone number. We will bill you for any fees at that time, if any.
To withdraw your consent with DSHS Contract Management Section
To inform us that you no longer wish to receive future notices and disclosures in electronic
format you may:
i. decline to sign a document from within your signing session, and on the subsequent page,
select the check-box indicating you wish to withdraw your consent, or you may;
ii. send us an email to alison.joffrion@hhsc.state.tx.us and in the body of such request you must
state your email, full name, mailing address, and telephone number. We do not need any other
information from you to withdraw consent.. The consequences of your withdrawing consent for
online documents will be that transactions may take a longer time to process..
Required hardware and software
The minimum system requirements for using the DocuSign system may change over time. The
current system requirements are found here: https://support.docusign.com/guides/signer-guide-
signing-system-requirements.
Acknowledging your access and consent to receive and sign documents electronically
To confirm to us that you can access this information electronically, which will be similar to
other electronic notices and disclosures that we will provide to you, please confirm that you have
read this ERSD, and(i)that you are able to print on paper or electronically save this ERSD for
your future reference and access; or(ii) that you are able to email this ERSD to an email address
where you will be able to print on paper or save it for your future reference and access. Further,
if you consent to receiving notices and disclosures exclusively in electronic format as described
herein, then select the check-box next to `I agree to use electronic records and signatures' before
clicking `CONTINUE' within the DocuSign system.
By selecting the check-box next to `I agree to use electronic records and signatures', you confirm
that:
• You can access and read this Electronic Record and Signature Disclosure; and
• You can print on paper this Electronic Record and Signature Disclosure, or save or send
this Electronic Record and Disclosure to a location where you can print it, for future
reference and access; and
• Until or unless you notify DSHS Contract Management Section as described above, you
consent to receive exclusively through electronic means all notices, disclosures,
authorizations, acknowledgements, and other documents that are required to be provided
or made available to you by DSHS Contract Management Section during the course of
your relationship with DSHS Contract Management Section.